肾透析医疗技术基础

MedicalandTechnicalBasics相关医学和技术基础2Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020肾脏生理一．生成尿液，排除代谢终末产物、毒物和药物二．调节体内水、电解质、渗透压和酸碱平衡三．调节血压四．分泌肾素、促红细胞生成素、1,25-(OH)2D3、前列腺素等3Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020血液透析的作用清除体内的毒素（弥散、对流、吸附）纠正酸碱平衡紊乱（弥散）清除体内过多的水份（超滤）纠正电解质失衡（弥散）4Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020Diffusion弥散Start开始时:DifferentConcentrations膜两侧浓度有差别End结束时:EqualConcentrations膜两侧浓度相同time弥散是微分子物质随机的运动可导致均匀分布的结果Diffusionisaconsequenceoftherandommovementofallmolecules(BrownianMovement).5Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020Ultrafiltration超滤TimePressureStart:End:Exertionofpressureononesideofthemembraneproducesfiltrationofwaterwithsolutes,aslongastheycanpassthemembrane.运用压力的作用将水份从膜一侧推到另一侧，膜孔够大时溶质也可以被挤出6Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020Adsorption吸附afterchemicaldisinfection?hollowfiverendotoxins内毒素-contactspace接触空间Virus病毒7Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020H2OwatersolublemoleculesFmmHgmmHgBBBDBDmmHgBmmHgDBDlow-flux低通透析器high-flux高通透析器Therapytypes治疗模式Hemodialysis血液透析Hemofiltration血液滤过Hemodiafiltration血液透析滤过弥散原理对流吸附弥散对流吸附8Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020Hemodialysis血液透析利用血液和透析液中溶质的浓度差别使溶质在弥散作用下通过半透膜随透析液排出Diffusivemetabolictransportthroughsemi-permeablemembraneswithbalanceofaconcentrationdifferencebetweenbloodanddialysisfluid.小分子物质可有效的被清除Smallmolecularsubstanceswillessentiallymoreeffective.BmmHgDBDHemodialysis血液透析andHemofiltration血液透析滤过Hemofiltration血液透析滤过可溶物质随着通过高通透性半透膜的液体流动而被清除（对流）。对流依靠跨膜压和膜的物理性质（面积、密度、质量、孔径）来实现。Solublesubstancesaresweptalonginafluidstreamthroughhighpermeablemembranes(convection).Theconvectiondependsonthetransmembranepressureandonmembranefeatureslikesize,density,andqualityofthepores(„cut-off-value“).清除高分子量物质（只要是低于膜孔的筛选值的物质）的有效方法Highmolecularesubstances,aslongastheyarebelowthe„cut-off-value“,willbeeliminatedinabetterway.9Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020HDF–Hemodiafiltration血液透析滤过结合两种治疗模式：血液透析和血液滤过结合由弥散产生的小分子物质的高清除率和由对流产生的中大分子物质的高清除率两种方式的优点。Combinationoftwodialysistechnics,hemodialysisandhemofiltration:highclearanceofconventionelsmallmoleculesbydiffusionlinkedwithhighclearanceofmiddlemoleculesbyconvection.mmHgBmmHgDBD10Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020ReplacementSolutionforHFandHDF置换液Na+mmol/lK+mmol/lCa2+mmol/lMg2+mmol/lCl-mmol/lLactatemmol/lGlucoseg/lOsmol.mmol/l135-1500-41.6-2.00.50-0.75100-11335-450-2.0285-312Na+mmol/lK+mmol/lCa2+mmol/lMg2+mmol/lCl-mmol/lBicarbon.mmol/lGlucoseg/lOsmol.mmol/l1400-41.50.5109-113351.0290-300常规离子范围常用配方11Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020RheaterheparinVVPVPAUFBLDSADPredilution前稀释Clearance清楚效果Sub.Volume置换液量FilterClotting滤器凝血Expensive花费Postdilution后稀释Clearance清除效果Sub.Volume置换液量HDF-Online在线透析滤过–Medical医学12Autoren:GünterNissenHeikoRiemenschneiderTrainingdocument,noupdateserviceThisdocumentmaynotbecopied,partlyorwhole,ormadebeaccessibletothirdpartieswithoutourpermissionandremainsthepropertyofB.BraunMedizintechnologieGmbHwithallrights.29/02/2020ClearanceinHD,HFandHDF各治疗模式的清除率0408012010102103104105Urea尿素氮Creatinine肌酐Vit.B12ß2-Microglob.AlbumineClear